Governments are like sharks. They need to keep moving or they die. For many decades governments have formed a consensus view that strenuous activity, and the appearance of strenuous activity, is the best way to show that you are working hard governing the country. The civil service must balance the farcical tension between real work and the appearance of work. Ministers are frequently distracted from important meetings and forced to spend time visiting places they don't need to visit and launching policies that are already happening just so they look busy.

Strenuous activity is also the best defence when problems emerge. Ministers can point to all their action to show how they have been working hard to solve the very problem that has just emerged. Nowhere is this more true than with public service reform. Whether it is welfare, education or health, a government that stands still is an easy target. A government moving at speed is harder to hit.

Every new government has to answer two questions: where are we going and why do we need to go there? For many voters the process of public service reform is boring. Governments struggle to hold their attention, unless there is a row. Everyone loves a row. But to justify the investment in time, energy and political capital there must be a compelling list of things that will get better. They must improve services for very many people and the destination must be good enough to justify the effort of the journey.

The uniqueness of the coalition is that it has embarked on major reform in every area at the same time. In the immediate post-election frenzy, the priority was to get the plans published and start bringing them to life. Obsessed by the last government's perceived squandering of its first term, the coalition wanted to move fast. Over the summer there was much back-slapping at how well the reform plans had been received. But this month has been a nasty shock as it has become clear that very few people properly understand what the government is doing or why it is doing it.

The prime minister's speech on Monday was to be the fightback, the moment when he set out his vision for public services. With much excitement, Number 10 sent a memo to all departments instructing them to use the word "modernisation" instead of "reform". Reform was thought too negative. Modernisation is exciting. Civil servants embarked on a vast deleting and editing operation as the word "reform" was ruthlessly hunted down and expelled from Westminster.

Despite this shift in tone, Downing Street was furious that everything the prime minister said was seen through the prism of its serious health problem. Cabinet on Tuesday was messy, as ministers complained about the plans for the NHS and the government's failure to explain itself.

Doctors have raised the tempo of the debate and, unlike teachers or policemen, they can comfortably play politics as public deference to medical professionals is strong. But government advisers are not alarmed. The coalition can win this fight. It will pass its health bill in the House of Commons and should get it through the Lords. The new health system will get built but the real risk is what happens then. If doctors are alienated and angry and patients worried and confused, the system won't work. The NHS treats almost a million people every day. It would take only a few high-profile deaths and hospital scandals to put the health secretary's job in doubt. Ultimately, this mess may even lose the coalition the next election.